Oregon State Seal Oregon Insurance Division: Protecting the Insurance-Buying Public.
Welcome | Site Search | What's New
*

Insurance Division

About the Division
Advisory Committees
Agent Information
Public Meetings
Company Information
Consumer Complaints
Consumer Information
Division Directory
Employment
    Opportunities
Enforcement Actions
F.A.Q.
Fees
Forms
In the News
Laws, Rules & Bulletins
Legislation
Links to Other Sites
Publications
Rates and Forms
Subject Index

Insurer forms and applications - Numeric Listing

Form # Title
1962
Word | PDF
Medical/Dental Negligence Claim Report
    * Instructions
2035
Word | PDF
Form I.S.S. and instructions
2036
Word | PDF
Form C.S.S. and instructions
2164 Financial Statement for Legal Expense Organization
2165 Qualifying Bond for Legal Expense
2166 Legal Expense Insurance List of Sales & Marketing Representatives
2167 Application for Certificate of Registration for Legal Expense Organization
    * Instructions
2168 Designation of Registered Office and Registered Agent by Legal Expense Organization
2169 Change of Registered Office and Registered Agent by Legal Expense Organization
2170 Application for Renewal of Certificate of Registration for Legal Expense Organization
2315 Annual Statement of Educational Institutions and Nonprofit Corporations Authorized to Issue Gift Annuities
2361 Affidavit for Lost Certificate of Authority
2805 Home Protection Insurer Bond
2851 Service Contracts Obligor Registration Application
    * Instructions
2944
Word | PDF
Security Deposit Release Request
3094 Organizational Bond
3095 Oregon Biographical Affidavit
3105 Application for Certificate of Authority
* Educational/Nonprofit
    * Affidavit
3106
Word | PDF
Application for Permit to Organize Insurer with or without Capital Stock
3112
Excel | PDF
Oregon Special Schedule P
* For Insurers authorized to write workers' compensation
3117 Health Care Service Contractor Bond
3118
Excel | PDF
Quarterly Enrollment Reporting Form
* Instructions
3237
Word | PDF
Network Adequacy Annual Summary
3238
Word | PDF
Utilization Review Annual Summary
3239
Word | PDF
Quality Assesment Annual Summary
3241
Word | PDF
Grievance Annual Report
3246
Word | PDF
Rating Organization License Application
3247
Word | PDF
Rating Organization Amended License Application
3305
Word | PDF
Application for Amended Certificate of Authority
    * Instructions
3309 Designation of Registered Office and Registered Agent by Insurer
3310 Change of Registered Office or Registered Agent by Insurer
    * Instructions
3359 Life Settlement Provider Bond
3430 External Review Referral Request
3431 Prompt Payment Data Report
    * Health insurers and health care service contractors
    * Instructions
  Application for Certificate of Authority
    * Domestic Home Protection Insurer
    * Domestic Insurer
    * Foreign Home Protection Insurer
    * Health Care Service Contractor (HCSC)
    * Insurance Companies
  Application for Reservation of Name
3630 Multiple Employer Welfare Arrangement Bond
3639
Word | PDF
External Review Annual Summary
3928
Word | PDF
Surplus Lines Licensee Affidavit for Purchasing Groups

Form A Statement Regarding the Acquisition of Control of Merger with a Domestic Insurer
Form B Insurance Holding Company System Annual Registration
Form C Summary of Registration Statement
Form D Prior Notice of a Transaction

Life Settlement Provider Application Packet
3012 Disclosure Statement for Life Settlement Contracts (Provider)
3015
Word | PDF
Life Settlement Provider License Application
3025 Life Settlement Broker Appointment/Affiliation Notice

  OIGA Assessment Recoupment

Tax Forms
   * Excise
   * Life and Health 20012002200320042005
   * Ocean Marine 20042005
   * Property & Casualty 20012002200320042005
   * Risk Retention 200320042005

Return to Top

*
DCBS Home Page | Oregon.gov | Disclaimer of Liability

We'd like to hear from you.
Send comments, questions or suggestions to Oregon Insurance Division or call (503) 947-7980

This document was last revised on January 20, 2006 .